IS BIGGER BETTER? Surgeons are bringing more complex sinus cases to the outpatient setting.

Here at Mercy Clinic: ENT Surgery Center, ENT procedures are what we do all day, every day — more than 2,200 procedures each year. Read on for 6 of our tricks of the trade for achieving profitability, good outcomes and short turnover times.

Be realistic
Two forces are at work: Surgeons are increasingly trying to bring bigger sinus cases to the outpatient setting, and sicker patients are presenting, having put off treatment longer due to higher deductibles and co-pays.

But profitability goes down as cases get bigger. They require more (and more specialized) supplies, take longer in the OR and result in less predictable PACU stays. It's not like doing tonsillectomies, ear tubes and sinus reductions, which you can turn over quickly and time practically to the minute. Carefully monitor case costs and times, and determine whether Medicare, Medicaid or another payor makes cases viable for your center.

Further, you must determine if bigger cases are safe. When the surgeon wants to do a combination of sinus, uvula and tonsil work, you must consider the patient's disease states and ASA status before green-lighting. We have very careful parameters set up for what's acceptable in the ASC, but it can be helpful to remind surgeons and their offices that cases that don't fit the criteria may be split into 2 procedures if you're to host them.

Stack the schedule
To keep procedures and turnover flowing in the surgery suite and to strategically ease the burden on PACU staff, we stack like procedures. We do all ear tube procedures in a row, and those are organized by age. Same goes for tonsillectomy and adenoidectomy. That way, beds will rotate quickly enough to keep up, and patients recovering from sinus surgery won't hold up the works.

Attack PONV in every patient
PONV is an inherent concern in ENT procedures, because (1) there's a lot of work on the airway, which causes swelling around the tonsil beds (which in turn leads to gagging and nausea issues), and (2) there's a lot of work in the ear canal, which can cause inner-ear issues (which in turn leads to nausea). A scopolamine patch is a must for some ENT patients. In higher-risk patients — those who meet at least a couple of the "overweight, fair, over 40, fertile, female" criteria — we use a propofol drip instead of anesthetic gases, so these patients wake up with the smallest possible chance they'll experience and be delayed by PONV issues. For patients with known PONV, our surgeons will prescribe 1 dose of aprepitant (Emend) to be taken the day before surgery. We also dose them on the day of surgery. These patients are always amazed to not be sick after surgery, and our PACU nurses are happy because delays are minimized.

Involve caregivers to comfort children
Parents or guardians accompany pediatric patients to the pre-op area, where they assist with changing into surgical attire and listen in on the post-op teaching. We rarely allow a parent into the surgery suite for induction as it can be very stressful for the patient and parent— it may even have a negative impact on the surgical experience. When a child goes to sleep holding his parent's hand, he'll hold the parent accountable for his feeling lousy when he wakes. Parents also tend to have a hard time seeing their children under general anesthesia.

It's better to escort caregivers to the recovery room as soon as the child is awake, usually about 15 to 20 minutes after surgery. That's when their mere presence smoothens the process. Parents sound right and smell right and hold their children right — something we simply can't do. So we take advantage of those benefits, and have the caregivers talk with the child and help him eat ice chips to move him toward discharge. Involving the caregivers in this way actually makes the post-op process more efficient, rather than dragging it out.

Use latest-generation packing
The old method of packing the sinuses for surgery wasn't pleasant for anyone — patient or practitioner. Not to mention that the removal process was a smelly, sticky business. Now we have a new generation of chemical packing that holds sinus tissue in place and dissolves over time with the prescribed post-op nasal irrigations.

The new packing materials can be put in with a splint that holds the septum in place, allowing air to move back and forth. This allows for normal breathing, which in turn can help relieve the pain and sinus pressure that patients experienced with the old gauze-and-Vaseline method. We call to check on all patients on post-op day 1, and when we talk to sinus patients now, there's a big difference. They tend to report a little pressure, minimal if any pain, and that they don't need the pain medications we've prescribed. That huge ball of gauze we used to put in there was one of the main patient dissatisfiers.

Further, new-generation packing is impregnated with hemostasis medications, which help control post-op bleeding. This is an issue for patients at home because it's unpleasant but, more importantly, sinus bleeding lengthens PACU stays. Swallowed blood can lead to PONV. If blood gets in the stomach, patients will throw up. If you want to get sinus patients up and on their way effectively and efficiently, using the latest packings is a crucial start.

Don't be afraid of new procedures
Direct laryngoscopy is now profitable for ASCs to do, so over the past 2 years, we've begun to do more of those procedures. Post-op airway difficulties are a concern with direct laryngoscopy, but our ENT group wanted to try it in the ASC, and we've not had a negative outcome yet. Depending on your surgeons' and staff's comfort levels, it's a procedure you might want to consider adding.

The key to handling direct laryngosocopy in particular is to schedule those cases first in the day, because airway issues tend to happen right away — when patients are just being extubated, or are just leaving the OR — rather than later. And patients who make it to PACU without trouble are vastly more likely to have an issue during their recovery in your facility than at home. But that doesn't mean we send these patients — or any others — on their way before they and their caregivers are comfortable going. Sometimes, we ask that direct laryngoscopy patients stay in town until mid-afternoon, just to make sure there are no complications before they go home (many patients come from more rural areas to have surgery at our facility).

With others who aren't quite up to leaving, whether it's due to their comfort or their caregivers', we have a graduated system. Once they're medically ready to be discharged from PACU, we take them to a third bay that's supplied with drinks, crackers and cookies. From there, they can go to the waiting room, relax and watch TV. We give these patients and their caregivers warmed blankets, make ourselves available to answer questions and don't pressure them to leave until they're truly ready to walk out the door.